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					Pacific Soccer Camp Application Form
   Please print this completed Camp Application Form and post or fax together with your payment details to:
   Pacific Soccer, Po Box 239, Manly NSW 2095, (Australia)
   Phone: (02) 9977 2992
   Fax: (02) 9977 0376
   ABN: 98 056 624 492


Applicant Details:
Name:

Address:

Suburb:                                                      Postcode:                         Contact No.:

Age:                   Sex: M / F     Club that you play for:

Please Tick this box if your child requires Specialist Goalkeeping Coaching
N.B. Goalkeeping coaching is only available at the Eastwood location with Outfield players.


Camp Details:
  Date: 3.07.2006 to 7.07.2006                       Day: Monday to Friday                     Time: 9.00 am to 1.00 pm

  Ages: For boys and girls aged 6-14 years                      Fee:     $155 inc. GST (check group and family discounts)

  Please √ Camp you wish to attend:

  Canterbury                                           Frenchs Forest                                     Kirrawee

  Castle Hill                                          Hunters Hill                                       Mona Vale

  Caringbah                                            Hurstville                                         Pennant Hills

  Chatswood                                             Kellyville                                        Quakers Hill

  Eastwood

  Payment Details: (Please Tick)

  I enclose payment now by: Cheque            Money Order                Mastercard           Bankcard            Visa

  CARD NUMBER                                                                             EXPIRY DATE




  CARD HOLDERS NAME: ______________________________________

  AMOUNT: $ _____________________________________________

  SIGNATURE: _______________________________________________


 CONSENT FORM: I, the undersigned, approve of this application and in doing so do agree that the Pacific Soccer Camp and its
 officers and servants are free and clear of all responsibility whatsoever for any injury or illness that may occur during the applicants
 participation in the above mentioned activity.
 Data Protection Statement and Consent
 If you do not wish to receive any information about our services and products please tick this box

 Signature of Parent or Guardian:…………………………………. Date:………………………………….

				
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posted:10/16/2011
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